ENLISTING THE ARMED FORCES TO PROTECT REPRODUCTIVE HEALTH AND RIGHTS: LESSONS LEARNED FROM NINE COUNTRIES TECHNICAL REPORT Technical Support Division Culture, Gender and Human Rights Branch Copyright © UNFPA New York, 18 August 2003 ISBN 0-89714-676-X www.unfpa.org 2 FOREWORD UNFPA has been at the forefront of involving men in reproductive and sexual health for decades, and especially since the International Conference on Population and Development (ICPD, 1994). Over the years, we have learned a great deal about how to positively engage men to take charge of their own reproductive and sexual well-being and support that of their partners. One of the fundamental lessons is to reach out to men where they are rather than expect them to seek out reproductive and sexual health information and services. Employment-based programmes have been one of the most successful ways of doing this. Drawing on pre-Cairo successes with employment-based population and family life education programmes, UNFPA has worked in several countries with a major employer – the military – to introduce, expand and enhance reproductive and sexual health information and services. The enormous human, social and economic toll of HIV/AIDS and the increased awareness of women’s vulnerability to gender-based violence, have given greater urgency to this approach. Many countries have planned or are now implementing projects targeting men in uniform as a way to promote HIV prevention, engage men as partners in gender equity and the reduction of gender-based violence and improve their own and their partners’ reproductive health status and protect their rights. To map out what can be done in future interventions related to reproductive health and gender equity within this key institution, this publication draws lessons from nine country case studies and a global review of emerging programming and policy issues for enlisting the armed forces in reproductive health, including preventing HIV/AIDS and promoting gender equity. It starts by summarizing key lessons from the nine countries. This is followed by an introduction, a synopsis of each case study, and a comparative analysis drawn from the country findings. The comparative analysis examines what works in successful programmes, what does not and what is left out. It also identifies remaining challenges and opportunities. Finally, we outline global changes in the military context relevant to future programming. I trust that this review will stimulate debate, future programming and increased funding to enlist armed forces as critical partners in both peacetime and conflict situations in our national and international efforts to promote reproductive health and rights and gender equity. Mari Simonen Director, Technical Support Division UNFPA 3 ACKNOWLEDGEMENTS Copyright © UNFPA New York, 18 August 2003 ISBN 0-89714-676-X This publication and the case studies were made possible by:  A generous contribution from the Swedish International Development Agency (SIDA)  UNFPA interregional and country programmes core funds It was carried out under the direction of:  Mari Simonen, Director, Technical Support Division, UNFPA New York  Sylvie I. Cohen, Acting Chief, Culture, Gender and Human Rights Branch, Technical Support Division, UNFPA New York, managed the project, conducted research and wrote the report In close collaboration with: Margaret Arilha, CST Advisor, Latin America and the Caribbean Michèle Burger, International Consultant Manuel Carballo, International Consultant, IMCH Pedro Garzon Castaneda, Former CST Advisor, Latin America and the Caribbean Jimona Cilloniz, International Consultant, ICMH Dr. Akinyele Dairo, Project Officer, Africa Division Colonel Alexander Gudzovsky, National Project Director, Ukraine Helen Jackson, CST Advisor, Southern Africa Janet Jensen, Editor, UNFPA, New York Dr. Tumurbaatar Luvsansambuu, National consultant, Mongolia Dr. Oswaldo Montoya, National Consultant, Nicaragua Luis Mora, CST Advisor, Latin America and the Caribbean Yrene Ocampos, National Consultant, Paraguay Jim Paige, International Consultant Joseph Pitso, National Consultant, Botswana University Andrey Poshtaruk, UNFPA project coordinator, Ukraine Dr. Jean de Dieu Marie Rakotomanga, National Consultant, Madagascar Dr. Azucena Maria Saballos, UNFPA Project Manager, Nicaragua Dr. Jean Sehonou, National Consultant, Benin Captain Anne-Mary Shigwedha, National Consultant, Namibia Humberto Vaquero, National Consultant, Ecuador Peter Lunding, Consultant, UNFPA, New York. And effective support from the UNFPA staff, UNFPA Representatives and designated UNFPA case study focal points in each country office, namely: 4 Edwige Adekambi, National Programme Officer, Benin Alba Aguirre, UNFPA Representative, Ecuador Bernard Coquelin, Former UNFPA Representative, Madagascar Pamela Delargy, Chief, Humanitarian Reponse Unit, UNFPA New York Philippe Delanne, UNFPA Representative, Benin Linda Demers, Former UNFPA Representative, Mongolia Dr. Ider Dungerjav, National consultant, Mongolia Alexandrine Dzagobo, National Advisor on Reproductive Health, Benin Manuelita Escobar, National Programme Officer, Paraguay Tomas Jimenez, UNFPA Representative, Nicaragua Mustapha Kemal, UNFPA Representative, Namibia Agathe Lawson, UNFPA Representative, Botswana Priya Marwal, Technical Officer, Humanitarian Response Unit, UNFPA, New York Julitta Onabanjo, Senior Technical Officer, HIV/AIDS Branch, UNFPA, New York Pierre Robinson, Assistant Representative, Madagascar Dr. Soyoltoya, National Programme Officer, Mongolia Dorcas Temane, Assistant Representative, Botswana Borys Vornik, National Programme Officer, Ukraine 5 ABREVIATIONS AIDS Acquired Immune Deficiency Syndrome BCC Behaviour Change Communications (Formerly IEC: Information, Education and Communication) CST Country Technical Services Team GBV Gender-based Violence HIV Human Immunodeficiency Virus ICPD International Conference on Population and Development ICMH International Centre for Migration and Health KAP Knowledge, Attitudes and Practices PLWA People Living with AIDS RH Reproductive Health RSH Reproductive and Sexual Health RR Reproductive Rights STD Sexually Transmitted Disease STI Sexually Transmitted Infection SWAps Sector Wide Approaches UNAIDS Joint United Nations Programme on HIV/AIDS UNDPKO United Nations Department of Peacekeeping Operations UNFPA United Nations Population Fund UNIFEM United Nations Development Fund for Women VCCT Voluntary and Confidential Counselling and Testing VCT Voluntary Counselling and Testing WHO World Health Organization 6 CONTENTS Acknowledgements Abbreviations Executive Summary of Key Findings and Lessons Institutional opportunities and challenges for the partnership Building human capacity to address reproductive health, HIV and gender equity Behaviour change communication strategies Providing quality reproductive health services, including HIV/AIDS prevention Addressing gender issues Tapping political will Mobilizing more resources Recommended next steps for donors Introduction Rationale for the study The ICPD vision: Benefits of partnering with men in the military Conceptual framework Methodology: Where and how? Limitations of the study Synopsis of Country Case Studies Benin Botswana Ecuador Madagascar Mongolia Namibia Nicaragua Paraguay Ukraine Comparative Analysis of the Nine UNFPA Country Case Studies National contexts Entry points for the projects Cross-sectoral collaboration Human capacity strategies Behaviour change communication strategies Reproductive health service delivery strategies Promotion of gender equity Institutionalization and prospects for expansion Changing Contexts for Partnering with the Armed Forces on Reproductive Health, HIV and Gender Issues 7 Changing roles, demographics and socio-economics of national military forces Growing numbers of female military personnel Military in national budgets: a privileged sector in developing countries Increased attention to vulnerabilities of military personnel Unequal power relations between armed forces and civilians Global agreements Opportunities for change and emerging good practices in prevention Challenges for HIV prevention in the military Policies governing military life, including family relations Human rights issues Unresolved gender issues Conclusion Conclusion: The Military Institution as a Social Change Agent References and Other Sources Annex: A Comparison of Military, Education and Health Expenditures in Developing Countries 8 EXECUTIVE SUMMARY OF KEY FINDINGS AND LESSONS Background This comparative study of country experiences across regions was undertaken as part of a UNFPA interregional project ‘Improving Gender Perspective, Reproductive Health and HIV/AIDS Prevention through Stronger Partnership with the Military’ (project number INT/01/PM3). It was conducted by UNFPA’s Technical Support Division, with generous support from the Swedish International Development Agency and through collaboration with the UNFPA Technical Assistance Programme regional advisors, country offices and national consultants. Its purpose is to inform future programming by identifying effective approaches for working with men in the uniformed services in reproductive and sexual health from a gender perspective. Although UNFPA has long cooperated with the military in the areas of family planning and family life education, its growing cooperation with an institution that operates in unique political and social contexts – in times of peace or conflict – has not been well documented. Experience sharing is needed to scale-up or sustain effective interventions and guide future programming. Cross-regional exchange of experiences is expected to enhance UNFPA’s practical knowledge and leadership role in an area where it clearly has a comparative advantage regarding gender issues, reproductive health/reproductive rights promotion, and the fight against HIV/AIDS. Equipped with practical insights into the implementation process, UNFPA offices and their national partners should be able to improve existing programmes or introduce new ones. To compare implementation strategies in the military that integrate reproductive and sexual health and gender issues, we established a conceptual framework to review the nature of the partnership; the extent and quality of reproductive health services and information, including for HIV/AIDS prevention; and gender mainstreaming. Country experiences are from: Benin, Botswana, Madagascar and Namibia in Africa; Ecuador, Nicaragua and Paraguay in Latin America; Mongolia in Asia; and Ukraine in Eastern Europe. The case studies focused on institutional changes, rather than actual impact on epidemiology and behaviour. They sought to identify the range of implementation approaches used so far, their commonalities and differences. A common query was: What is working and needs to be continued or expanded? What is not working and needs a new more strategic approach? And finally, what has not been addressed at all? The main lessons follow: 9 Institutional opportunities and challenges for the partnership Selecting a strategic focus for the partnership between donors and armed forces The projects reviewed fell in three broad categories, focusing on: • Prevention of HIV and other sexually transmitted infections in Botswana Mongolia and Namibia; • Improvement of armed forces’ reproductive health service delivery capacity in Benin; Ecuador, and Madagascar; • Educating military personnel about population and reproductive health issues, in Botswana and Ecuador, and integrating reproductive and sexual health services and education in Nicaragua and Paraguay. The review examined if and how the origin of the project – including its funding source, and whether it derived from earlier projects – affected the attention given to gender issues, quality of care and broader reproductive health messages as well as the project’s prospects for scaling-up and institutionalization. Since most of the projects studied did not conduct a needs assessment at the outset, strategic design decisions, such as the selection of priority beneficiary groups, depend on the degree of verticality of the intervention and preferences of donors, rather than on actual needs. In peacetime, a larger difference in the focus of the reproductive and sexual health interventions with the armed forces seems to account from donor’s interests rather than country-specific development context and lessons learned from experience. Another is the visibility of the HIV/AIDS epidemic in the country. Donors may need to show short-term results, and hence, take a vertical approach. However, in order to implement the comprehensive ICPD vision, projects with the military should attempt to expand from the vertical and short- term programmatic approaches to HIV/AIDS prevention -favoured by many large donors- and encompass all components of reproductive health, including quality of care, reproductive rights, and gender-based violence, and mainstream gender in laws and codes of conducts. Most projects supported by HIV-focused funds, such as UNAIDS, tend to address HIV prevention in a rather vertical and medical manner; much less attention is given to other reproductive health components such as family planning, maternal and child health, and gender perspectives. Even though these projects focus on prevention, critical components such as voluntary counselling and testing (VCT), sustainable condom provision and 10 education on gender sensitive relations, seem to have been an after-thought, and the reproductive health services component is limited. Moreover, many of the surveyed HIV-only projects focus on educating young male soldiers and conscripts, but leave out higher-level officers, service providers, permanent staff, female staff, and civilian populations. On the other hand, the broader reproductive health projects, which stem from former family planning or population education activities, try to address larger concerns and take a more comprehensive approach to reproductive health. When these projects contributed to building a reproductive health infrastructure, they tended to focus more on service delivery and less on education for behaviour change. However, the addition of an HIV prevention component – especially provision of condoms – is often an after-thought. Most projects on rehabilitation of reproductive health services encompass service providers, families of permanent staff and in some cases, surrounding civilian populations. They tend to overlook the needs of young recruits. Who to work with inside the institution? Most projects favour one department over others, often either the health or training departments, but rarely both. Because the choice of a lead department is critical to the success of a project, a thorough understanding of military structure and its culture is essential to effectively channel support to project activities. A major challenge to integration and coordination among departments comes from the organizational structure of the military itself, which is typically compartmentalized and hierarchical. Advocacy at the highest level possible, to promote the benefits of working across departments or divisions, is needed. Mid- level health officers will rarely have the clout to influence activities outside of their own department – orders from above are needed to make this happen. Choosing the lead department to implement a project is a key strategic decision. This decision affects not only the overall focus and strategies of the intervention – for instance, the balance between education and service provision – but also the prospects for institutionalization and expansion. Unfortunately, the choice of the department often reflects the history of the project and its previous entry points, rather than a well thought-out strategy. The choice of lead departments to manage the project is not always based on a feasibility study and knowledge of the military structure. Different departments have different comparative advantages. Health departments, for instance, afford access to the military health service delivery infrastructure and can [...]... Public Health and the Armed Forces work together Their cooperation initiated the integration of national standards for reproductive and sexual health into the Armed Forces health care systems The project is also exemplary in terms of the support it has garnered throughout the military and for its close monitoring and supervision Like several other projects reviewed in this book, it builds on the idea... condom use and gender-based violence Lessons from Benin The coordination and cooperation between the Armed Forces, the Ministry of Health and UNFPA is exemplary The Armed Forces readily accepted the national health system’s management tools A commission is now studying how to institutionalize collaboration between the Ministry of Health and the Ministry of Defence to formalize training of personnel and integrate... spouses and families of the military, it strategically used the military health structure as a cost-effective way to reach them, and then to broaden its reach to involve men working in the armed forces The first phase of the project, ‘Strengthening Maternal Health, ’ integrated reproductive and sexual health services into the existing military health infrastructure It improved technical knowledge of health. .. Fieldwork: Project Name: October 2002 ‘Providing Reproductive Health Services in the Department of Health of the Armed Forces The first phase July 1999 through December 2003 focused on increasing the use of reproductive health services in five targeted military health centres The second phase focused on strengthening these health centres and the management of logistics skills of the Armed Forces Government... between health and social welfare units of the military and access to reproductive health commodities Condom programming and educational initiatives are interdependent Behaviour change communication that promotes the use of condoms is more likely to succeed if condoms are readily available 32 ECUADOR: Strengthening Maternal Health (Phase I) and Sexual and Reproductive Health for the Armed Forces and the. .. within the military, and between the military and civilian sectors and communities; Adaptation of these guidelines to the specific needs and characteristics of different military forces and groups, including the needs of women as staff, spouses, service contractors and neighbours; Strategies to ensure reliable procurement of reproductive health commodities, including supplies and re-supply of condoms, reproductive. .. materials and sharing lessons learned from other sexuality education projects carried out by, in this instance, the Ministry of Education, help reduce cost and redundancy Expanding the range of reproductive health services beyond family planning can help to expand the client base and encourage men’s health- seeking behaviour Look to the specific needs of the region (in this case, high unmet demand for... equality, into training Another major accomplishment was the integration of sexuality and love into the military training curriculum, using existing materials developed by other UNFPA-supported projects for the Ministry of Education, and using participatory teaching methods with adolescents and youth to stimulate their attendance and interest in these themes Finally, introducing reproductive heath into the. .. depending on the context, on maternal health and gender-based violence issues The political will to introduce reproductive and sexual health into the military arena is present and should be leveraged This commitment seems to stem from the military elites’ sense of social responsibility for the health of their workforce or a desire to assist civilian populations in crisis In any case, their concern... by the government and $280,000 by UNFPA The Central Office of Health Services for the Armed Services has primary responsibility for the project However, UNFPA and the Ministry of Health helped design the project Local NGOs, including SAF (health department of the Jesus Christ Church) and SALFA (health department of the Lutheran Church), provided management training FISA, the local affiliate of the . ENLISTING THE ARMED FORCES TO PROTECT REPRODUCTIVE HEALTH AND RIGHTS: LESSONS LEARNED FROM NINE COUNTRIES TECHNICAL. of their partners. One of the fundamental lessons is to reach out to men where they are rather than expect them to seek out reproductive and sexual health